CAR T-cell therapy and management of inflammatory emergencies

Chimeric antigen receptor (CAR) T-cell therapy is a new cell-based immunotherapy option for the treatment of refractory B-cell lymphomas and potentially other malignancies. In the USA and Europe two anti-CD19 CAR T-cell products have recently been approved for the treatment of diffuse large cell B-cell lymphomas refractory to conventional treatment options. The impressive response rates and the high proportion of permanent remission even in lymphoma patients with very little chance of a cure have caused great excitement. Many more trials are currently ongoing. Due to the special spectrum of toxicities that can be associated with this form of treatment, the adequate use of CAR T-cell treatment necessitates a comprehensive interdisciplinary cooperation, in which nephrologists must also be included. Besides late adverse side effects, such as prolonged cytopenia and on-target off-tumor effects, there are two additional and relatively common acute forms of toxicity that typically manifest within days after CAR-T administration and deserve special consideration: CRS (cytokine release syndrome) and ICANS (immune effector cell-associated neurotoxicity syndrome). A high level of vigilance and competence for action is necessary for their diagnosis and management as these complications can be fatal if not controlled.